GetReal24 Application

Online application for young adults who have aged out of Arkansas DHS foster care and have an interest in bettering themselves and becoming independent with the assistance of community resources and networking.

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Personal Information

Name*

FirstLast

Current Address*

Street AddressAddress Line 2CityStateZIP Code

Date of Birth*

Age*

Phone Number*

Email Address*

Gender*

Male

Female

Marital Status*

Single

Married

Divorced

Widowed

Do you have any children?*

Yes

No

If so, please list the name and age of the child(ren) and who has custody of each:

Name

Age

Who has Custody

Do you have siblings?

Yes

No

If so, list the name and age of your brother(s) and/or sister(s).

Name

Age

Race/Ethnicity*

American Indian or Alaska Native

Asian

Black or African American

Hispanic

White

American Indian or Alaska Native and White

Asian and White

Black or African American and White

Preferred Lanuage*

English

Spanish

Other

Religious Preference

Christian

Muslim

Judaism

Buddhism

Hindu

None

Other

Release of Records*

Will you consent to release your DHS records to CES Independent Living Program?

Yes

No

Emergency Contact

Name

FirstLast

Relationship to You

Their Phone Number

Email

Caseworker Information

Name

FirstLast

Office Phone

Cell Phone

Support System

List

Name

Phone Number

Relationship to You

Please list 3 relatives/friends/caring adults that are actively involved in your life.

Physical Characteristics

Height*

Weight*

Tattoo(s)

Do you have tattoos?*

Yes

No

If yes, give a general description and location of each.

Special Needs

Do you have any special needs that might be relevant to your participation in the program?*

Yes

No

If yes, please describe.

Residential Status

If you didn’t list an address in the Personal Information section, where do you sleep at night?

How long have you been in your current location?*

How many people also live in that location?*

How long are you permitted to stay there?*

Employment and Income

Do you have any non-employment sources of Income? Check all that apply.

Child Support

Social Security Disability

Medicaid

Unemployment

Food Stamps

TANF (Temporary Assistance for Needy Families)

WIC (Women, Infants, and Children)

Are you currently employed?*

Yes

No

If so, where?

What is your monthly income?*

What is your current hourly rate?

Supervisor's Name

FirstLast

Supervisor's Phone Number

Education

Are you currently enrolled in school?*

Yes

No

If so, where? What grade?

What is the last grade you completed?*

7th

8th

9th

10th

11th

12th

Do you have a high school diploma or GED?*

Yes

No

What year did you graduate high school or complete your GED?

Have you ever attended college or trade school?*

Yes

No

If you have not completed high school would you be willing to:

Work on/obtain GED

Finish high school and graduate

No

Higher Education Information

Where and what did you study?*

Do you plan to continue to pursue college or trade school?*

Legal Information

Have you ever been arrested?*

Yes

No

If yes, when and for what have you been arrested? List each occurrence if you’ve been arrested more than once.*

Have you ever been charged with a crime?*

Yes

No

If yes, list all charges, the date of each, whether each was a felony or misdemeanor, and whether you were convicted of the charge.*

Do you currently have any outstanding warrants for your arrest?*

Yes

No

If yes, for what?*

Have you ever been in jail or a correctional facility?*

Yes

No

If yes, when, for what, and for how long for each incident?*

Are you currently on probation or parole?*

Yes

No

If yes, for what?*

If you have a probation officer, provide his or her contact information.

FirstLast

Probation Officer's Phone Number

Do you have any pending court dates?*

Yes

No

If yes, list the date(s) and reason.

Protection Order Information

Have you ever applied for a protection order?*

Yes

No

If yes, from whom did you seek protection and for what reason?*

Health Information

Do you have any current health issues?*

Yes

No

If yes, please describe.*

Do you currently take any medications?*

Yes

No

If yes, list each medication, the reason you take each, and the currently prescribed dosage for each.*

Do you have any allergies?*

Yes

No

If yes, please list them and whether you receive treatment or medication for such.*

Have you ever been hospitalized?*

Yes

No

If yes, please list the date(s) and reason(s) you have been hospitalized.*

Pregnancy

If female, are you pregnant?*

Yes

No

Due Date*

Are you seeking prenatal care?*

Yes

No

Is the father involved or plan to be involved?*

Yes

No

If you have a physician, please list his or her name and contact information.

FirstLast

Phone

Tobacco

Do you use any form of tobacco or tobacco substitute such as e-cigarettes?*

Yes

No

What forms of tobacco or tobacco substitute do you use (cigarettes, cigars or pipe tobacco, smokeless tobacco, E-cigarettes)?*

How long have you used each type or tobacco or tobacco substitute, and how much do you use of each?*

Alcohol

Do you consume alcohol?*

Yes

No

How much alcohol do you consume?*

Have you ever received treatment for alcohol addiction?*

Yes

No

If you have received treatment for alcohol addiction, list the date(s) and location(s) of such treatment.*

Drug Use

Have you ever used illegal drugs?*

Yes

No

What illegal drugs have you used?*

When was the last time you used illegal drugs?*

Goals

Please list your life goals.*

Where do you want to be in 2-5 years?*

Where do you want to be in 10 years?*

What kind of job do you want to have by the time you turn 21?*

Who do you know personally that is successful and has a life like you want? Describe their life.*

List any reasons you feel that might cause you not to achieve your life goals.*